This document provides guidance on neonatal resuscitation from the 8th edition of the Neonatal Resuscitation Program. It discusses that most newborns transition well after birth, but some require assistance with breathing or extensive intervention. It outlines the initial assessment of the newborn including airway, breathing, circulation, and interventions such as positive pressure ventilation, chest compressions, and medications if needed. It emphasizes effective communication and teamwork during resuscitation. The focus is on assisting the transition to extrauterine life through ventilation of the lungs and supporting circulation as needed.

1. NEONATAL RESUSCITATION PROGRAM
8TH EDITION
Dr BRBK

2. INTRODUCTION
• Most newborns make the cardio respiratory transition to
extra uterine life without intervention.
• Many will require assistance to begin breathing
• A small number will require extensive intervention.
• After birth, approximately 4% to 10% of term and late
preterm newborns will receive positive pressure ventilation.
• Only 1 to 3 per 1,000 will receive chest compressions or
emergency medications.

3. Transition From Fetal to Neonatal Respiration

4. Respiratory failure
INSUFFICIENT SUPPLY OF
O2 AND REMOVAL OF CO2
ACIDOSIS; CO2 INCREASES
• Fetal monitoring - a decrease in
activity, loss of heart rate variability,
and heart rate decelerations.
A series of gasps followed by
apnea and bradycardia.

5. Why do newborns require a different approach to
resuscitation than adults?
A. Newborns – require resuscitation because of heart disease.
B. Newborn resuscitation is usually the result of
respiratory failure.

6. The focus of neonatal resuscitation is effective
ventilation of the baby’s lungs.

7. Neonatal Resuscitation Program
• 1. Initial Assessment
• 2. Airway (A)
• 3. Breathing (B): PPV, oxygen, CPAP
• 4. Circulation (C)
If severe bradycardia persists despite assisted ventilation;
supported by performing chest compressions coordinated
with PPV.
• 5. Drug (D)
If severe bradycardia persists despite assisted ventilation
and coordinated compressions, the Drug epinephrine is
administered as PPV and chest compressions continue.

9. Focus on team work
Team work : Poor teamwork and
communication were the most common root
causes for potentially preventable infant
deaths in the delivery room.
Effective communication-
closed loop communication
Accurate documentation
Post resuscitation team debriefing
Pre-resuscitation team briefing
• Assess perinatal risk factors.
• Identify a team leader.
• Delegate tasks.
• Identify who will document events
as they occur.
• Determine what supplies and
equipment will be needed.
• Identify how to call for additional
help.

10. NRP KEY BEHAVIORAL SKILLS
1. Know your environment
2. Use available information
3. Anticipation and plan
4. Identify your team leader
5. Communicate effectively

11. 6. Delegate workload
7. Allocate attention wisely
8. Use available resources
9. Call for help
10. Maintain professional behavior

12. Members of an effective resuscitation team
• share information?
OR
• work quietly and independently?

13. Preparing for resuscitation
• Questions you ask before birth ?
• Personnel needed for delivery
• Supplies and equipment should be available

14. • What questions should you ask before every
birth ?

15. ❶ What is the expected gestational age?
❷ Is the amniotic fluid clear?
❸ Are there any additional risk factors?
❹What is our umbilical cord management?

16. What personnel should be present at delivery?
• Every birth should be attended by atleast 1 qualified individual, skilled in
the initial steps of newborn care and positive-pressure ventilation (PPV),
whose only responsibility is management of the newly born baby.
• If risk factors are present, at least 2 qualified people should be present solely
to manage the baby.
• A qualified team with full resuscitation skills should be identified and
immediately available for every resuscitation.

17. Initial Steps of Newborn Care

19. Vigorous
term newborn
If answer to all the three
questions is ‘yes’

20. • Non vigorous and preterm
newborns
• If the answer to any of the
initial assessment is NO, the
baby should be brought to a
radiant warmer as additional
interventions may be required

21. Low-risk newborn: full-term, good tone,
crying.
High-risk newborn: preterm, poor tone, not
crying

22. 1. Radiant warmer
Leave the baby uncovered
Apply a servo-controlled temperature sensor
Avoid both hypothermia and overheating.
Baby’s temperature maintained between 36.5°C and
37.5°C.
2. Position head and neck to open
airway
Supine
Sniffing
Avoid hyperextension or flexion
Shoulder roll
3. If needed, clear secretions from the airway.
•Baby is not breathing, is gasping
•Secretions are obstructing the airway
•Difficulty clearing their secretions
•Meconium-stained fluid
•If you anticipate starting PPV
Mouth before nose
Not to suction vigorously or deeply
Bulb syringe/ suction catheter(80-100 mm Hg)
4. DRYING
Not necessary for
less than 32 weeks
•5. Brief
additional tactile
stimulation
• Gently rub the
newborn’s back,
trunk, or
extremities.

23. Correct: “sniffing” position INCORRECT: Hyperextension

24. Which image shows the correct way to position a newborn’s head to open
the airway (A, B, or C)?

25. How do you assess the newborn’s response to the initial steps?
• Respirations
• Heart rate
Auscultation- counting the number of beats in 6 seconds and
multiplying by 10.
Pulse oximetry or electronic cardiac (ECG) monitor leads

26. Pulse oximeter
Proper placement of the pulse oximeter sensor is
important.
• The sensor and source positioned opposite
• It may be helpful to cover the sensor to shield it from
light in the room.
• Place the pulse oximeter sensor on the right hand or
wrist.
Target preductal sats after birth

27. Baby is breathing and the heart rate is at least 100
but the baby appears persistently cyanotic/ has labored breathing?

28. Supplemental oxygen
When the pulse oximeter reading remains below the target range for the
baby’s age in minutes.

29. Supplemental oxygen
1. Compressed air and oxygen
2. Blender
3. Flow meter
• Adjust the flowmeter to 10 L/min.
• Start with the blender set to 30% oxygen.
• Adjust the oxygen concentration as needed to achieve the
oxygen saturation target.

30. CPAP
If the baby has labored breathing or persistently low oxygen
saturation

31. True/ False
• Free flow oxygen can be given by?
A. Oxygen tubing
B. Mask attached to flow inflating bag
C. Mask attached to self inflating bag
D. T- piece resuscitator

32. True/ False
• Indications of CPAP?
A. Labored breathing
B. Persistent cyanosis/ saturations below target despite
supplemental oxygen
C. Baby is apneic / gasping

33. Positive Pressure Ventilation

34. PPV
Start PPV
• Baby is not breathing (apnea) OR gasping
• Baby appears to be breathing, but the heart rate is below 100
bpm.
• Oxygen saturation below the target despite supplemental
oxygen or CPAP
When indicated, PPV should be started within
1 minute of birth.

35. Devices used to deliver PPV
• Three types of devices are commonly used for ventilation.
1. Self inflating bag
2. Flow inflating bag
3. T- piece resuscitator

36. There are 8 basic parts
➊ Gas outlet
❺ Gas inlet
❷ PEEP valve (optional)
❻ Gas tubing
❸ Manometer
❼ Oxygen reservoir
❹ Pressure-release valve
❽ Valve assembly

37. Flow inflating bag

38. T- piece resuscitator

39. Adjusting PIP

40. One hand technique

41. Two hand technique with jaw thrust

42. What concentration of oxygen should be used to start PPV?
• Greater than or equal to 35 weeks’ gestation set the blender to
21% oxygen.
• Less than 35 weeks’ gestation, set the blender to 21% to 30%
oxygen.
• Set the flowmeter to 10 L/minute

43. Rate for PPV
Rate of 40 to 60 breaths per minute.
Count out loud
Rhythm-“Breathe, Two, Three; Breathe, Two, Three;
Breathe....(squeeze) Two... ...Three... ...(release...
... ... ... ....)

44. Pressures
• Start with a PIP of 20 to 25 cm H2O.
• Full-term babies may require 30-40 cm H2O
• When PEEP is used, the suggested initial setting is 5 cm H2O
• Caution in preterm- visual assessment of chest movement may be less
reliable
• It is possible to achieve successful ventilation without apparent chest
movement.

45. Position of baby’s head and neck
Place the right size mask/ tight seal
Oxygen concentration
Adequate pressures/ rate
Position yourself at baby’s head end

46. Evaluate the baby’s response to PPV
• The most important indicator of successful PPV is a rising heart
rate.
• With a stethoscope, pulse oximeter, or an electronic cardiac
(ECG) monitor.

48. Ventilation Corrective steps
MRSOPA

49. Air leak between the cheek and bridge of the nose is common.

51. Alternative airways

52. When should an alternative airway be considered?
• If PPV with a face mask does not result in clinical
improvement.
• If PPV lasts for more than a few minutes
• If chest compressions are necessary
• Special circumstances- An endotracheal tube provides the
most reliable airway access
(1) suspected diaphragmatic hernia
(2) for surfactant administration,
(3) for direct tracheal suction if the airway is obstructed by thick
secretions.

53. Depth of insertion
Nasotragal length :
The estimated insertion depth (cm) is
NTL +1 cm.
Gestational age

54. • How much time should be
allowed for an intubation attempt?
• How do you confirm that the endotracheal tube is in the
trachea?
Detecting exhaled CO2
Rapidly rising heart

55. • The colorimetric CO2 detector is a purple or
blue color before
detecting exhaled CO2
The detector turns yellow in the presence of
exhaled CO2 .

56. Thyroid and cricoid pressure provided by an assistant may improve
visualization of the larynx.
Press downward and toward the baby’s right ear.

57. LMA
can’t ventilate and can’t
intubate”
• congenital anomalies
involving the mouth,
lip,tongue, palate or neck
• small mandible or large
tongue,
Limitations:
•Suctioning of secretions
•Intratracheal medications
•High ventilation
pressures
•Very small neonates

58. LMA
• The mask covers the
glottis like a cap and
the inflated cuff
creates a seal against
the hypopharynx

59. Chest compressions

60. Chest compressions
Indication
Heart rate remains less than 60 bpm after at least 30 seconds of
PPV that inflates the lungs, as evidenced by chest movement
with ventilation.

61. Where?
Thumbs should be placed either side-by-side or one on top of the other
in the center of the sternum.
From the head of the bed From the side

62. Depth of compression
Approximately one-third of the anterior-posterior (AP)
diameter of the chest then release the pressure to allow
the heart to refill.
Thumbs should remain in contact with the chest during
both compression and release
90 compressions : 30 breaths per minute
“One-and-Two-and-Three and-Breathe-and;
One-and-Two-and-Three-and-Breathe-and……”
• Compress the chest with each counted number(“One, Two, Three”).
• Release the chest between each number(“-and-”).
• Pause compressions and give a positive-pressure breath when the
compressor calls out “breathe-and”.

63. • When chest compressions are started, increase the oxygen
concentration to 100%.
• When should you check the baby’s HR?
Wait 60 seconds after starting coordinated chest compressions and
ventilation.
• How should you assess the baby’s heart rate response during
compressions?
• ECG monitor- preferred method
• Auscultation, pulse oximeter

64. When do you stop chest compressions?
• When the heart rate is 60 bpm or higher.
• Return to giving PPV at the faster rate of 40 to 60 breaths per
minute.
If the heart rate is less than 60 bpm, check the quality of
ventilation and compressions.

65. Medications

66. Epinephrine
Indication
If heart rate remains below 60 bpm after
•At least 30 seconds of PPV that inflates the lungs
and
• Another 60 seconds of chest compressions coordinated with PPV using 100% oxygen.

68. Response to Epinephrine
• Assess the heart rate 1 minute after epinephrine administration.
• If the heart rate is less than 60 bpm after the first dose of intravenous or dose, can
repeat the dose every 3 to 5 minutes.
• If started at the lower end of the dosage range, consider increasing subsequent
doses.
• Do not exceed the maximum recommended dose.

69. Volume expanders

70. If there is a confirmed absence of heart rate after 20 minutes of resuscitation,
it is reasonable to stop resuscitative efforts;
however, the decision to continue or discontinue should be individualized.

71. Does the presence of meconium-stained amniotic fluid change the approach to the
initial steps?
Meconium-stained fluid and a vigorous newborn
• With good respiratory effort and muscle tone, the baby may stay with the mother to
receive the initial steps of newborn care.
• Use a bulb syringe to gently clear meconium-stained secretions from the mouth and nose.
Meconium-stained fluid and a non-vigorous newborn
• Has depressed respirations or poor muscle tone, bring the baby to the radiant warmer and
perform the initial steps of newborn care .
• Use a bulb syringe to clear secretions from the mouth and nose.
• Not breathing or the heart rate is less than 100 bpm after the initial steps , proceed with
PPV.
• Routine intubation for tracheal suction is not suggested.

72. Resuscitation and Stabilization of
Babies Born Preterm
Thin skin, large surface area
Immature lungs that lack surfactant
Immature tissues are more easily
damaged by oxygen.
Immature blood vessels in the brain
Polythylene plastic bag/wrap
CPAP, lowest inflation pressures,
PEEP, surfactant
Blended oxygen- 21-30%
Gentle handling, avoid head low,
excess PIP/PEEP, rapid changes in
CO2, rapid boluses

73. For babies born at less than 32weeks’
•Place a thermal mattress under the
blanket on the radiant warmer.
•Wrap the baby in a polyethylene plastic
bag or wrap.

79. Thank
You